Inadequate cervical cancer screening among mid-aged Australian women who have experienced partner violence

Abstract

Partner violence is linked to cervical cancer and other gynaecological conditions. However, results of current research into associations between partner violence and cervical cancer screening have been inconclusive. Therefore, the current research investigates the association between partner violence and inadequate cervical cancer screening.
Participants were 7312 women aged 45-50 years who responded to the Australian Longitudinal Study on Women's Health population-based surveys in 1996 and 2004. The women self-reported frequency of Pap smears via mailed questionnaire.
Women who had experienced partner violence at least eight years earlier, compared with those who had not, were more likely to report current inadequate screening (OR: 1.42, 95%CI: 1.21; 1.66). After adjusting for known barriers to preventive screening (education, income management, marital status, general practitioner visits, chronic conditions) and depression, partner violence was independently associated with inadequate Pap tests (OR: 1.20, 95%CI: 1.01; 1.42). This association was no longer significant once access to a GP of choice was added to the model (OR: 1.18, 95%CI: 0.99; 1.40).
The significance of this study lies not just in confirming a negative relationship between cervical cancer screening and partner violence, but in suggesting that good access to a physician of choice appears to significantly decrease this negative relationship.

Full text

Inadequate cervical cancer screening among mid-aged Australian women who have
experienced partner violence
Deborah Loxton
a,
⁎, Jennifer Powers
a
, Margot Schofield
b
, Rafat Hussain
c
, Stacey Hosking
a
a
Research Centre for Gender, Health and Ageing, University of Newcastle, Australia
b
La Trobe University, Victoria, Australia
c
School of Health and School of Rural Medicine, University of New England, Australia
abstractarticle info
Available online 5 November 2008
Keywords:
Cancer screening
Intimate partner violence
Domestic violence
Pap test
Cervical cancer
Objectives. Partner violence is linked to cervical cancer and other gynaecological conditions. However,
results of current research into associations between partner violence and cervical cancer screening have
been inconclusive. Therefore, the current research investigates the association between partner violence and
inadequate cervical cancer screening.
Methods. Participants were 7312 women aged 45–50 years who responded to the Australian Longitudinal
Study on Women's Health population-based surveys in 1996 and 2004. The women self-reported frequency
of Pap smears via mailed questionnaire.
Results. Women who had experienced partner violence at least eight years earlier, compared with those
who had not, were more likely to report current inadequate screening (OR: 1.42, 95%CI: 1.21; 1.66). After
adjusting for known barriers to preventive screening (education, income management, marital status,
general practitioner visits, chronic conditions) and depression, partner violence was independently
associated with inadequate Pap tests (OR: 1.20, 95%CI: 1.01; 1.42). This association was no longer significant
once access to a GP of choice was added to the model (OR: 1.18, 95%CI: 0.99; 1.40).
Conclusions. The significance of this study lies not just in confirming a negative relationship between
cervical cancer screening and partner violence, but in suggesting that good access to a physician of choice
appears to significantly decrease this negative relationship.
© 2008 Elsevier Inc. All rights reserved.
Introduction
Cervical cancer is a significant cause of morbidity and mortality
in women (World Health Organisation, 2003; American Cancer
Society, 2007). Screening procedures with good sensitivity and
specificity such as Pap tests are widely available for early detection
of cervical cancer. Current guidelines recommend Pap tests at least
every three years in the USA (American Cancer Society, 2008), and
screening at two yearly intervals in Australia (Australian Institute of
Health and Welfare, 2008). The uptake of cervical cancer screening
through Pap tests is relatively high, with screening rates of 82% for
American women aged 25 and older in 2000 (American Cancer
Society, 2008), and 61% of Australian women aged 20 to 69
(Australian Institute of Health and Welfare, 2008). Nevertheless,
overall figures tend to mask the differentials in uptake of cervical
screening, with studies showing the rates to be considerably lower
among some groups of women (Harris, 2000; Lockwood-Rayer-
mann, 2004; Lofters et al., 2007).
It is essential to determine whether those at high risk are being
screened at optimal rates, and to identify potential barriers to
screening. For example, barriers to cervical cancer screening include
marital status, low socio-economic status and limited education, as
well as chronic conditions such as diabetes, depression and obesity
(Wee et al., 2000; Savage and Clarke, 2001; Weinrab et al., 2002;
Hewitt et al., 2004; Pirraglia et al., 2004; Ostbye et al., 2005). There are
indications that intimate partner violence could be associated with
inadequate preventive cervical cancer screening. For instance, a
history of violence in women with cervical cancer has been associated
with advanced stage of cancer at diagnosis (Modesitt et al., 2006). The
current paper examines partner violence as a potential barrier to
adequate screening for cervical cancer.
Around 20% of women in western countries will experience
partner violence in their lifetime (Tjaden and Thoennes, 20 00;
Australian Bureau of Statistics, 2006). This is a serious public health
issue in its own right (World Health Organization, 2002). Research has
demonstrated a consistent association worldwide between partner
violence and a wide range of health problems including cardiovascular
disorders, gastrointestinal symptoms and illnesses, and increased
reporting of aches, pains and fatigue (McCauley et al., 1995; Coker
et al., 2000; Kernic et al., 2000; Loxton et al., 2006). Partner violence
Preventive Medicine 48 (2009) 184–188
⁎Corresponding author.
E-mail address: Deborah.Loxton@newcastle.edu.au (D. Loxton).
0091-7435/$ –see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2008.10.019
Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

has also been linked to increased risk of cervical cancer and other
gynaecological problems (Campbell et al., 2000; Loxton et al., 2006).
Furthermore, women who have lived with a violent partner have a
higher risk than other women of sexually transmitted infections and
should therefore be considered at higher risk for cervical cancer
(Plichta and Abraham,1996; Augenbraun et al., 2001; Taft et al., 2004).
Consequently, it is important to know whether women who have
experienced partner violence are engaging in adequate preventive
screening behaviour. However, there has been limited research in this
area. A US study that found women (aged 18–54) who had
experienced physical or sexual partner violence were more likely to
undergo regular Pap smear screening (Lemon et al., 2002). Similar
results were found in an Australian study of a representative sample of
18–23 year old women (Taft et al., 2004). However, the findings
mentioned earlier concerning late stage diagnosis of cervical cancer
among women who had experienced violence (Modesitt et al., 2006)
suggest that screening among women who have experienced partner
violence might be less than optimal.
Identification of risk factors for inadequate screening for cervical
cancer allows us to develop effective screening recommendations to
address those risk factors. For example, age and family history have
well known associations with cervical cancer, and have been
incorporated into screening recommendations (Australian Institute
of Health and Welfare, 2008). The current study examined the
relationship between partner violence and preventive screening
using a large representative community based sample of mid-aged
Australian women, and adjusted for previously identified barriers
(marital status, socio-economic status, chronic conditions) to pre-
ventive screening in order to determine the relationships between
partner violence and Pap testing. It also examined the impact of
perceived access to a GP of choice on the relationship between partner
violence and cervical cancer screening after controlling for known
confounders.
Methods
The Australian Longitudinal Study on Women's Health (ALSWH) is
a prospective study of factors affecting the health and well-being of
three cohorts of women. The womenwere randomly selected from the
national Medicare database that includes all permanent residents of
Australia, with over-sampling in rural and remote areas. This paper
focuses on the mid-aged women who were 45–50 years in 1996. The
consent rate for participation in this 20 year study was 54% and
comparison with the 1996 Census indicates the respondents were
reasonably representative of women of this age in the general
population, but with some over-representation of women with
tertiary education. Further details of the recruitment methods and
response rates have been described elsewhere (Brown et al., 1998; Lee
et al., 2005).
Participants
Of the 13,716 women who responded to Survey 1 (S1) in 1996,
10,905 women (80%) respondedto Survey 4 (S4) in 2004,1052 women
could not be contacted, 886 women were contacted but did not return
S4, 635 women had withdrawn from the project, 203 women were
deceased and 35 women were unable to fill in S4 due to incapacity.
After exclusion of 3273 women who had had a hysterectomy, 249
women who had experienced partner violence since S1 and 71
women who had missing data for partner violence at S1 or S4, 7312
women were included in the analyses.
Measures
Mailed questionnaires were used to collect data about health
factors, health service use, health behaviours and socio-demographic
factors. Surrogate measures of socio-economic status included the
highest educational qualification achieved (S1) and whether the
women had difficulty managing on their available income (S4).
Residential postcode was used to categorise area of residence as
urban, rural or remote (S1).
Partner violence
Have you ever been in a violent relationship with a partner/spouse
was asked in S1 and S4. Women were also asked if they currently live
with a partner/spouse (S4).
Health status
Women were asked: In the past three years, have you been diagnosed
with or treated for: diabetes, heart disease, stroke, thrombosis or
breast, cervical or bowel cancer. A woman was considered to have a
chronic physical condition if she gave an affirmative response to any of
these conditions (S4).
Depression
The 10 item Center for Epidemiological Studies Depression scale
was included in S4. The recommended cut-off score of 10 or more was
used to indicate depression (Andresen et al., 1994).
Health service use
At S4, women reported on the number of times they had consulted
a general practitioner (GP) in the last year (0–2, 3–6, 7 or more visits).
Women were asked to rate their access to health service providers. A
woman was considered to have good GP access if she rated her ease of
seeing the GP of her choice as excellent, very good or good (S4).
Preventive screening
Cervical screening was considered adequate for women who
reported having had a Pap test in the past two years (S4). Women were
also asked if a doctor had checked their blood pressure and cholesterol
in the last three years (S4).
Statistical analyses
Various characteristics are associated with Pap screening and
partner violence: health service use, physical conditions, depression
and socio-demographic factors such as education, ability to manage
on available income, marital status, area of residence and age.
Likelihood-ratio chi-square statistics were used to test whether
these characteristics were associated with partner violence. Two-
tailed tests with pvalues less than or equal to 0.05 were considered
statistically significant.
Separate multivariable logistic regression models were built to
examine the relationships between partner violence at S1 and
subsequent inadequacy of Pap smears at S4. Women who had not
experienced partner violence at S1 were the reference group. Firstly,
odds ratios were estimated from models that included only partner
violence as the independent variable. Secondly the models were
adjusted for socio-demographic and health factors. Thirdly GP access
was added to the adjusted models to determine whether this factor
explained the difference in screening between womenwho had or had
not experienced partner violence. In addition, all models were
adjusted for area of residence to allow for the purposeful over-
sampling of women in rural and remote areas at S1. Due to the small
age range (53–58 years at S4), models were not adjusted for age. All
analyses were performed with SAS statistical software, version 9.1
(SAS Institute Inc, 1999).
Results
At S1, 15% of 13,716 women had experienced partner violence
compared with 13% of 10,905 women at S4. Women who had
185D. Loxton et al. / Preventive Medicine 48 (2009) 184–188

experienced partner violence were more likely to be uncontactable
(28%) or incapable (eg dementia, stroke) or deceased (21%) than
respondents (15%) at S4. Of the 7312 women included in the analyses,
13% had experienced partner violence by S1. Table 1 shows
associations between partner violence and socio-demographic char-
acteristics. Women who had experienced partner violence had more
difficulty managing on their available income (51% versus 33%) and
were less likely to be living with a partner (59% versus 81%) than
women who had never experienced partner violence.
Partner violence was significantly associated with more GP visits
in the previous year, worse access to a GP of choice, the presence of
a chronic physical condition and depression (Table 2). Women who
had experienced partner violence were equally likely to have had
their blood pressure and cholesterol checked relative to other
women.
Both unadjusted and adjusted odds ratios (OR) for inadequacy of
cervical cancer screening are presented in Table 3. Higher odds of
inadequate Pap tests were associated with previous partner violence
(unadjusted OR 1.42, 95%CI 1.21, 1.66). After adjusting for known
confounders, the odds ratio for inadequate Pap testing was still
significant (Table 3). However when GP access was added to the
adjusted model, the odds of inadequate Pap tests were not
significantly associated with partner violence (OR 1.18, 95%CI 0.99,
1.40).
Discussion
The present paper showed that for mid-aged women, partner
violence at least eight years earlier was associated with current
inadequate Pap testing. This finding contrasts with those of two
previous studies (Lemon et al., 2002; Taft et al., 2004). The age of the
women in the current study, which was focused on women in mid-
age, may account for some of these differences. One of the previous
studies was based on data collected from the Younger cohort of the
ALSWH, who were in their twenties; findings indicated associations
between partner violence and increased Pap testing (Taft et al., 2004).
A smaller US study found younger women and women who had
experienced physical or sexual, rather than psychological partner
violence were more likely to report adequate Pap screening (Lemon et
al., 2002). Overall, the results suggest that relationships between
partner violence and Pap screening might be contingent upon the age
of the women concerned, with younger women more likely to have
adequate screening. Alternatively, this difference may represent a
temporal cohort effect.
It is possible that younger women might be more likely to
undertake Pap tests than mid-age women due to the associated need
to obtain contraceptives. However, this does not explain why women
who experience partner violence are more inclined in the case of
younger women, or less inclined in the case of mid-aged women, to
undergo Pap testing than other women in their age groups.
In our analysis, partner violence was associated with a range of
factors that have been shown to act as barriers to adequate cervical
cancer screening, including cohabitation, lower socio-economic
status, education, the presence of a chronic condition and depression
(Yelsma,1996; Coker et al., 2000; Wee et al., 2000; Savage and Clarke,
2001; Weinrab et al., 2002; Pirraglia et al., 2004; Ostbye et al., 2005). It
is possible that because women with a history of partner violence
were less likely to be cohabiting, they saw less need for routine Pap
testing. Yet, even when these factors were adjusted for in the
multivariable regression, the associations between partner violence
and inadequate Pap testing remained statistically significant.
Cervical cancer screening is freely available in Australia. Therefore,
service cost and/or a lack of health insurance are not potential barriers
to screening, although associated costs (eg. travel) could interfere with
women's ability to take part in screening programs. Nevertheless,
while women who have experienced partner violence could be
adversely affected by associated costs, the association between
Table 1
Socio-demographic characteristics of women by experience of partner violence
between Survey 1 in 1996 and Survey 4 in 2004, Australia
Partner violence No partner violence
n=990 (%) n=6322 (%)
Area of residence
Urban 34.9 36.7
Rural 57.4 57.0
Remote 7.8 6.3
Highest educational qualification achieved⁎
Less than higher school certificate 44.2 40.2
Higher school certificate 18.1 17.1
Trade/certificate/diploma 20.4 21.2
University degree 17.3 21.5
Difficult managing on income⁎
Not 48.9 67.2
Sometimes 31.6 23.6
Always 19.5 9.2
Currently living with partner or spouse⁎59.2 80.8
Percentages weighted to allow for over-sampling of women living in rural and remote
areas.
⁎pb.05.
Table 2
Ever been in a violent relationship with partner/spouse in Survey 1, 1996 by health,
health service use and adequacy of screening in Survey 4, 2004, Australia
Characteristics in 2004 Partner
violence =
No partner
violence
n=990 (%) n=6322 (%)
Number of general practitioner visits in the last year⁎
0–2 38.6 44.7
3–6 44.0 45.2
7 or more 17.4 10.1
Good access to GP of choice⁎67.2 74.4
Any chronic physical condition⁎15.3 8.5
Depressed (CESD10≥10)⁎30.5 16.2
Blood pressure checked by a doctor 90.8 91.3
Cholesterol checked by a doctor 65.1 68.2
Regular Pap test (in the last 2 years)⁎75.1 81.3
Percentages weighted to allow for over-sampling of women living in rural and remote
areas.
GP: general practitioner.
CESD10: 10 item Center for Epidemiological Studies Depression Scale.
⁎pb.01.
Table 3
Odds ratios (OR) and 95% confidence intervals (CI) for women who had experienced
partner violence at Survey 1 in 1996, of inadequatecervical cancer screening at Survey 4
in 2004, relative to women who had never experienced partner violence, Australia
Ever lived in a violent relationship
with a partner/spouse
n
Unadjusted OR (CI) 7306 1.42 (1.21; 1.66)⁎
Adjusted OR (CI)
a
7035 1.20 (1.01; 1.42)⁎
Adjusted OR (CI)
a
and preferred GP access 6978 1.18 (0.99; 1.40)
GP: general practitioner.
Of the 1422 women with inadequate screening in 2004, 243 had experienced partner
violence by 1996.
Of the 5884 women with adequate screening in 2004, 747 had experienced partner
violence by 1996.
Partner violence in 1996 was unknown for 6 women. Unadjusted OR = 243=747ðÞ
1179=5137ðÞ
=1:42
⁎pb.05.
a
Adjusted for area of residence, education, difficulty managing on income,
cohabitation status, number of GP visits, any chronic physical condition and depression.
186 D. Loxton et al. / Preventive Medicine 48 (2009) 184–188

partner violence and inadequate screening remained significant even
after adjustment for socio-economic status.
In Australia, cervical screening services are provided as part of
mainstream health services with general practitioners (GP) perform-
ing approximately 80% of Pap smears (Australian Institute of Health
and Welfare, 2008). The results clearly showed that women who had
experienced partner violence attended the GP more often than other
women. This is consistent with past research (Loxton et al., 2004), and
further demonstrates that service access is not a barrier to GP service
delivery. However, women who had experienced partner violence did
report poorer access to a GP of their choice. Furthermore, after
adjusting for the other socio-demographic and health factors, access
to a GP of choice had a small additional effect that reduced the odds
ratios for inadequate Pap smears among women who experienced
partner violence, relative to those who had not.
Interestingly, screening levels for blood pressure and cholesterol
were the same for women who had and those who had not
experienced partner violence, countering the argument that doctors
may not be encouraging screening (Harris, 2000). Taken together, the
results suggest that there is something about partner violence itself
that might be preventing mid-aged women from undertaking
screening for cervical cancer. In addition, it appears as though having
access to a GP of choice might act to mitigate the effect of partner
violence on cervical cancer screening.
Past research has indicated a strong association between partner
violence and sexual abuse (Campbell and Soeken, 1999) which might
affect the willingness of women to undergo procedures that can be
considered invasive. The results of the current study could be seen as
supporting this notion. Women who had experienced partner violence
were as likely to undergo non-invasive procedures, such as cholesterol
and blood pressure checks, as women who had not experienced
partner violence. However, these findings require further investiga-
tions to determine the underlying mechanisms that explain the
associations between partner violence and inadequate cervical cancer
screening. A related issue concerns the relationship between the
patient and the GP. Access to a GP of choice infers that women feel
comfortable with their GP, which might encourage cervical cancer
screening. This could be of particular importance to women who have
lived with violent partners. However, the association was small and
requires further research.
The prevalence of partner violence in the current study is lower
than that found in the population of Australian women (Australian
Bureau of Statistics, 2006), although the age ranges are not directly
comparable between the two surveys. The single item that was used to
identify women who had experienced partner violence was likely to
lead to an under-estimate of partnerviolence prevalence (Robbe et al.,
1996). Another influence was difficulty contacting women who had
experienced partner violence. This was evident in the time between
the first questionnaire in 1996 and the fourth questionnaire in 2004
and likely to be a reason for non-response at the initial mailout in
1996. Furthermore, the self-report measures used in this study might
also limit the findings (Bowman et al., 1997; Canfell et al., 2006).
However, the study also has strengths. The use of a large representa-
tive community sample is rare in partner violence research, and the
longitudinal nature of the data adds further strength to the findings.
Conclusion
The findings show that partner violence could be a previously
unidentified barrier to preventive screening among mid-aged women.
Given that preventive screening for cancer is associated with
improved health outcomes (Gornick et al., 2004) and since partner
violence itself appears to be a risk factor for cervical cancer and late
stage diagnosis (Robbe et al., 1996; Modesitt et al., 2006; Loxton et al.,
2006), identifying ways of encouraging these women to undertake
regular screening is very important. Improved participation in cancer
screening has been found where women receive a letter of invitation,
educational material (Hewitt et al., 2002; Katz et al., 2007)and/or
telephone reminders (Dietrich et al., 2006). However, the efficacy of
these methods for encouraging women who have experienced partner
violence to undergo screening procedures is unknown. Further
research will be needed to determine the effectiveness of these
strategies for women who have experienced partner violence.
Conflict of interest statement
All authors declare that there are no conflicts of interest.
Acknowledgments
The research on which this paper is based was conducted as part of
the Australian Longitudinal Study on Women's Health, The University
of Newcastle and The University of Queensland. We are grateful to the
Australian Government Department of Health and Ageing for funding
and to the women who provided the survey data. We would like to
thank the two anonymous reviewers for their comments which
improved the quality of this paper.
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